N.J. Admin. Code § 10:49-5.8

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:49-5.8 - Services available for beneficiaries eligible for NJ FamilyCare-Plan H

(a) Effective for dates of service on or after July 1, 2007, all beneficiaries previously covered under Plan H are covered under NJ FamilyCare Plan D. The information in (b) through (g) below applies only to claims for former NJ FamilyCare Plan H beneficiaries with dates of service prior to July 1, 2007.

(b) Childless adults whose income is below 100 percent of the Federal poverty level and who do not qualify for WFNJ/GA and who were enrolled in NJ FamilyCare on July 1, 2002 shall be eligible to receive the NJ FamilyCare Plan H service package.

(c) Restricted alien parents who are enrolled in NJ FamilyCare on November 1, 2003, shall receive the Plan H service package.

(d) Out-of-plan community-based mental health services shall be limited to 60 service days per calendar year and shall be eligible for payment on a fee-for-service basis.

1. Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:77A) shall not be eligible for payment under NJ FamilyCare-Plan H.

2. NJ FamilyCare-Plan H beneficiaries under age 21 who are receiving services under the Division of Child Behavioral Health Services may secure additional mental health services if the services are authorized by the Contracted Systems Administrator or other agent authorized by the Department of Human Services and included in a plan of care.

(e) No behavioral health out-of-plan service of any kind, where the place of service is a hospital, shall be a covered service, unless provided in an approved psychiatric hospital to a beneficiary who is receiving services under the Division of Child Behavioral Health Services.

(f) The services listed below shall be available to beneficiaries eligible for NJ FamilyCare-Plan H, when medically necessary and when provided through the network of an HMO selected by the beneficiary.

1. Advanced practice nurse services;

2. Ambulance--medical emergency only;

3. Ambulatory surgery in an outpatient hospital setting only;

4. Clinic services (free standing)--ambulatory;

5. Diabetic supplies/equipment;

6. Durable Medical equipment-limited benefit, only covered when a medically necessary part of the beneficiary's inpatient hospital discharge plan;

7. Emergency room services;

8. Federally qualified health centers (FQHC) primary care services;

9. Home health care services (limited benefits);

10. Inpatient hospital (non-behavioral health related);

11. Laboratory services;

12. Outpatient hospital (non-mental health related);

13. Physician services;

14. Prescription drugs (excludes over the counter medications); and

15. Radiological services.

(g) The following services shall be available to NJ FamilyCare-Plan H beneficiaries on a fee-for-service basis:

1. Abortion (elective/induced); and

2. Mental health services in the community, including psychological services, up to a maximum of 60 days per calendar year;

i. Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:77A) are not eligible for payment under NJ FamilyCare-Plan H.

ii. NJ FamilyCare-Plan H beneficiaries under age 21 who are receiving services under the Division of Child Behavioral Health Services may be eligible for additional mental health and mental health rehabilitation services as authorized by the Contracted Systems Administrator. (See N.J.A.C. 10:49-5.8(d) ).

(h) Additional mental health and mental health rehabilitation services as listed below may be available to beneficiaries under age 21 who are eligible for NJ FamilyCare-Plan H under fee-for-service receiving services from the Division of Child Behavioral Health Services. All services shall first be authorized by the Contracted Systems Administrator, the Division of Medical Assistance and Health Services or other agent authorized by the Department of Human Services and shall be included in an approved plan of care.

1. Care coordination by a care management organization (CMO) (see N.J.A.C. 10:73);

2. Psychiatric services provided in an inpatient psychiatric hospital setting (see N.J.A.C. 10:52);

3. Mental health rehabilitation services provided in residential childcare facilities (as defined in N.J.A.C. 10:127 and licensed by DHS/DYFS), children's group homes (as defined in N.J.A.C. 10:128 and licensed by DHS/DYFS), or psychiatric community residences for youth (as defined in N.J.A.C. 10:37B and licensed by DHS/DMHS);

4. Behavioral assistance services for children, youth or young adults (see N.J.A.C. 10:77-4);

5. Mobil response and stabilization management services for children, youth or young adults under EPSDT (see N.J.A.C. 10:77-6); and

6. Intensive in-community mental health rehabilitation services for children, youth or young adults under EPSDT (see N.J.A.C. 10:77-5).

N.J. Admin. Code § 10:49-5.8

Special New Rule, R.2002 d.214, effective 6/10/2002.
See: 34 N.J.R. 2338(a).
Special amendment, R.2003 d.417, effective 9/26/2003 (operative November 1, 2003).
See: 35 N.J.R. 4913(a).
Rewrote the section.
Amended by R.2004 d.8, effective 1/5/2004.
See: 35 N.J.R. 2620(a), 35 N.J.R. 4204(a), 36 N.J.R. 189(a).
In (c), added 1; in (f), added 2i.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
In (e), added new 1, recodified existing 1, 2 as 2, 3, deleted existing 3.
Amended by R.2005 d.68, effective 2/22/2005.
See: 36 N.J.R. 379(a), 37 N.J.R. 659(a).
Rewrote the section.
Amended by R.2005 d.98, effective 4/4/2005.
See: 36 N.J.R. 1158(a), 37 N.J.R. 1022(a).
Rewrote (g).
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
Added new (a); and recodified former (a) through (g) as (b) through (h).